Study highlights tonsillectomy numbers and risks

Jan. 20, 2014
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Marvin Winkfield, stepfather of 13-year-old Jahi McMath, waits outside a courtroom in early January as a magistrate considered a dispute over the care of Jahi, declared brain dead after tonsil surgery. / AP/Ben Margot

by Michelle Healy, USA TODAY

by Michelle Healy, USA TODAY

Although the number of tonsillectomies performed on kids in the USA has declined drastically over the past 30 years, the surgery remains one of the most commonly performed on kids. A new study finds significant variation among hospitals when it comes to three aspects of tonsillectomy care â?? including how likely kids are to return to the hospital for complications.

In the study in February's Pediatrics, published online today, 8% of nearly 140,000 otherwise healthy children (ages 1 to 18) had to revisit the hospital within 30 days of having a tonsillectomy, 63.5% of whom going to the emergency department and 36.5% being admitted to the hospital. The revisit rate was as low as 3% in some hospitals and as high as 12.6% in others.

Bleeding was the most common reason for a hospital revisit (3%), followed by vomiting and dehydration (2.2%), pain (0.8% ) and infection (0.8%).

Older children, 10 to 18, were at higher risk of returning to the hospital because of bleeding and at lower risk of vomiting and dehydration, compared with children ages 1 to 2 years.

Multiple factors would probably play a role in reducing hospital revisits, says Sanjay Mahant, an associate professor of pediatrics at the University of Toronto and lead author of the study. Those would include surgical techniques, types of anesthesia used and parent education addressing the use of pain medication, post-surgery feeding and contact information in case of a concern or problem.

It's unclear "what the right mix or exact interaction is to reduce revisits," Mahant says.

The new study, conducted in collaboration with the Center for Pediatric Clinical Effectiveness at the Children's Hospital of Philadelphia, analyzed data collected from 2004 to 2010 on otherwise healthy kids who underwent same-day tonsillectomy (with or without adenoid removal surgery) at 36 free-standing children's hospitals.

The paper notes that children's hospitals account for one-third of pediatric hospitalizations in the USA, and its findings may not apply to hospitals that don't focus solely on children.

Along with revisits, researchers found wide variations between hospitals when it came to following recommended guidelines to administer dexamethasone (a steroid given to reduce nausea, vomiting and pain) on the day of surgery and not giving antibiotics before or after surgery.

"Some care providers used to believe antibiotics reduced bleeding, but that has not been shown to be the case," Mahant says.

About 70% of kids received dexamethasone, as recommended, and 31.1% received antibiotics. Across hospitals, administration of the steroid ranged from 0.3% to 98.8%. Use of antibiotics ranged from 2.7% to 92.6%.

Those findings show "there's a lot of room for improvement in two basic aspects" of tonsillectomy care "regarding the appropriate use of the steroid and what we would expect to be a restricted use of antibiotic," says Richard Rosenfeld, professor and chairman of otolaryngology at SUNY Downstate Medical Center in Brooklyn, N.Y. He was not involved in the new study.

The 8% revisit rate for tonsillectomy "is consistent with the range of other data out there," Rosenfeld says, but "what's interesting is that just over one-third of the patients ended up being readmitted."

"Revisits are not trivial if one in three end up being readmitted overnight," he says.

The study is "a reminder that this is a procedure that has risks, and those are particularly important when you consider that the benefits of the procedure are frequently uncertain," says David Goodman, a pediatrics professor at the Geisel School of Medicine at Dartmouth University in Hanover, N.H. He was not involved in the study.

Although "there is evidence that some children, in fact many children, benefit from tonsillectomy, nearly 100 years after the procedure has caught on, it's embarrassing that we don't have good, high-quality research about which children will benefit," Goodman says.

The one randomized clinical trial done on the effectiveness of tonsillectomy for obstructive sleep apnea was done in children ages 5 to 9, he says, but "a lot of these procedures are being done on children older and younger than that."

Recurrent throat infections were once the primary indication for tonsillectomy, but today account for about one-third of the approximately 530,000 surgeries performed annually on kids under age 15. About two-thirds are done to address airway obstructions that result in sleep-disordered breathing or sleep apnea, Rosenfeld says.

In a recent widely reported case, Oakland teenager Jahi McMath, 13, was declared brain dead in December after suffering hemorrhage and cardiac arrest in the intensive care unit at Children's Hospital Oakland after a tonsillectomy and other procedures to address sleep apnea. After a judge intervened, McMath's family had her transferred to an unnamed facility where she remains on a ventilator.